HISTORY OF PUBLIC HEALTH

Lectured by: Mark Raymund G. Nava, RMT, MPA, MSMT

St. Alexius College
Objectives:

Define Public Health and its components

Trace the history and development of Public Health
Discuss present situations concerning Public Health in the Philippines
Understand the social determinants of health

Definition of Public Health

The science and art of preventing disease, prolonging life, and promoting physical health
and efficiency through organized community efforts for the sanitation of the environment, the
control of community infections, the education of the individual in principles of personal
hygiene, the organization of medical and nursing service for the early diagnosis and preventive
treatment of disease, and the development of the social machinery which will ensure to every
individual in the community a standard of living adequate for the maintenance of health
- (Charles Edward Amory Winslow, 1920)
What is Health?
A state of complete physical, mental, and social well-being and not merely the absence of disease
or infirmity (WHO, 1948)
A resource for everyday life, not the objective of living. Health is a positive concept emphasizing
social and personal resources, as well as physical capacities. (Ottawa Charter for Health
Promotion, 1986)
Health is maintained and improved not only through the advancement and application of health
science, but also through the efforts and intelligent lifestyle choices of the individual and society
(LaLonde Report, 1974)
Every human being is the author of his own health or disease. (Buddha)
Four Broad Elements

Human Biology
Environment
Lifestyle
Health Organizations

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History of Public Health

Beginnings
The history of Public Health began when early Homo sapiens started communal living. Diseases
are caused by evil spirits or bad luck. Thus the presence of Shamans.
People started building cities
It was the exigencies of urban living, not considerations of health and disease, that required
sanitary engineering.
Rome: built aqueducts to transport water
Athens: built public fountains
Middle East: sewerage system
Hippocrates
Hippocrates noted the effect of food, of occupation, and especially of climate in causing disease
(De are, aquis et locis)
His book served as a guide for decisions regarding the location of urban sites in the Greco-Roman
world, and may be considered the first rational guide to the establishment of a science-based
public health
Dark Ages
Western Europe experienced a period of social and political disintegration. Large cities
disappeared, replaced by small villages surrounding the castles of landlords. (Feudalism)
The only unifying force was Christianity, and it was in the monasteries that the learning and culture
of the Greco-Roman world was preserved.
Monasteries constructed hospices to shelter travelers and sick persons
The most important disease of the period was LEPROSY. Exclusions of Lepers from community at
large.Leper houses (leprosaria) were established, and it is estimated that by the end of the twelfth
century there were 19,000 such houses throughout Europe. Isolation of cases of leprosy in
medieval times represents the earliest application of a public health practice still in use.
From Cities to Nations
As these changes occurred, the responsibility for communal functions was transferred from the
feudal lords and church leaders to lay councils presided over by a hierarchy of hereditary or
appointed officials.
Public health activities, such as overseeing the water supply and sewerage, street cleaning, and
supervision of the markets, fell under the jurisdiction of the councils.
Salerno Medical School
It was a lay organization, independent of the church. It welcomed students of any race or creed.
Faculty included women, who apparently dealt with obstetric issues, and the renowned peripatetic
scholar, Constantine the African (10201087), who translated many important Arabic works into
Latin

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Regimen Sanitatis Salernitanum

Si tibi deficiant medici, medici tibi fiant.
Haec tria: mens laeta, requies, moderata diaeta
The Regimen emphasized personal hygiene, diet, exercise, and temperance. It was the first
"health guide" for the masses.
The Renaissance
Bubonic plague, or "Black Death," swept over Europe and the Near East killing an estimated onefourth to one-third of the population between 1347 and 1351.
By the middle of the 15th century, the major cities of the region had established permanent boards
of health who were responsible for determining the existence of plague, establishing quarantine,
issuing health passes, arranging for the burial of plague victims and the fumigation of their
residences, and the management of lazarettos.
The boards maintained close relations with the local physicians who provided medical care and
prophylactic advice. As time passed, the boards expanded their purview to the control of markets,
sewage systems, water supplies, cemeteries, and the cleanliness of streets; and they took
jurisdiction over the professional activities of physicians and surgeons, the preparation and sale of
drugs, and the activities of beggars and prostitutes.
On Contagions and the Cure of Contagious Diseases
Written by Girolamo Fracastoro.
Proposed that epidemic diseases are caused by transferable tiny particles or "spores" that could
transmit infection by direct or indirect contact or even without contact over long distances.
I call fomites such things as clothes, linen, etc., which although not themselves corrupt, can
nevertheless foster the essential seeds of the contagion and thus cause infection. (1546)
Bills of Mortality
By early in the fifteenth century, the Italian boards of health instituted a system of death
registration, first for contagious diseases and subsequently for all diseases.The resulting bills of
mortality have provided continuous data on mortality in Italy from the Renaissance to the present.
In seventeenth-century London, analysis of bills of mortality by John Graunt in his epochal
treatise Natural and Political Observations Made Upon the Bills of Mortality (1662) laid the basis
for the modern use of statistics for the planning and evaluation of public health activities.
In English parishes, beginning in 1538, every burial required completion of a document that was
the precursor of the modern death certificate. This made the burial legal and allowed the
deceased's estate to be legally disposed of. The number of deaths were compiled on a weekly and
an annual basis
The Enlightenment Period
Johann Peter Frank, a leading clinician, medical educator, and hospital administrator, published a
six-volume treatise, System of a Complete Medical Policy, proposed a sweeping scheme of
governmental regulations and programs to protect the population against disease and to promote
health.
His proposals covered the entire life span from birth to death.

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Utilitarianism
Advocated by Jeremy Bentham
Society should be organized to give greater benefit for the greater number.
Constitutional Code(1830) - Bentham proposed radical new legislation dealing with such issues as
prison reform, the establishment of a ministry of health, birth control, and a variety of sanitary
measures.
Edwin Chadwick
Secretary of England's Poor Law Commission, established in 1834 to effectuate the New Poor
Law.
The Commission undertook a special study in 1839 of the prevalence and causation of preventable
diseases, particularly of the working poor.
General Report on the Sanitary Condition of the Labouring Population of Great Britain (1842) - is
considered one of the most important documents of modern public health.
Colonialism
The contagious diseases the colonizers brought with them frequently ravaged indigenous
populations.
Colonial sanitation and medical care was originally designed to serve the interests of the colonists.
However, after the establishment of biomedical science, there was enhanced incentive to control
the major tropical diseases that were interfering with the economic development of the colonies
Early 20th Century
Urgent health concern - infant mortality
Maternal and child health programs were initiated with an emphasis on nutrition, medical care, and,
eventually, health inspection in schools
High rates of occupational diseases and industrial injuries led to programs for industrial hygiene
and occupational health
The Late 20th Century
As infant and child mortality declined in the industrialized countries, life expectancy and the
proportions of the elderly in populations increased.
After World War II, epidemiological research concentrated on identifying risk factors for these and
other chronic diseases. A prominent role for behavioral factors was readily demonstrated

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What is Public Health?

In a 1920 article, American public health leader Charles-Edward Amory Winslow described public
health as, "the science and the art of preventing disease, prolonging life, and promoting physical
health."1 However, it can also be more than this. Public health may best be described as a
worldview, an organizing set of ideas which define a person's outlook. A public health worldview:

Views health as a continuum.

Is people and problem focused.

Takes a broad view of problems.

Seeks to prevent problems, not merely address them.

Each of these characteristics is described in greater detail below.

Health as a Continuum
A public health worldview recognizes that health is a complex construct. As noted in the preamble
to the World Health Organization's constitution, "health is a state of complete physical, mental and
social well-being and not merely the absence of disease or infirmity." 2 One is not simply "healthy"
or "unhealthy," but rather has a place somewhere along a continuum of health. This is best
illustrated by examining several real-world examples. Below are stories of three individuals. As you
read each account, consider these questions:

Is this person healthy?

What factors influence his or her health?

How could he or she be healthier?

Laxmi Kuwar
The story of Laxmi comes from the international relief agency Mennonite Central
Committee.3 Laxmi is a resident of Nepal, an impoverished nation located in south Asia between
India and China. She describes her experiences living with HIV in a country where infection has
long been considered a death sentence:
I have been living with HIV for 15 years. I got the virus from my husband after he returned from
working in India. He died 6 months after he was diagnosed. I had never heard of HIV until then.
I returned home to live with my mother. For 12 years I was always hiding. I was expecting death.
Three years ago a facilitator from Sakriya came to my house with medicine. I didnt want to see or
talk to him at first, but when he came back the second time I agreed to go with him to the hospital
for a treatment.
After 12 years of hiding Sakriya met me and gave a lot of support. I learned from Sakriya that I
could be treated and how to live and maintain my health. Now I help to counsel others about what
HIV is and how it is transferred.
I have new life now and I am excited.
Francis Serrano
Francis's story comes from an episode of a National Geographic Channel program on the science of
obesity.4 More than 64% of American adults are overweight or obese. Obesity increases the risk of
high blood pressure, diabetes, heart disease, stroke, cancer, liver and gallbladder disease, sleep

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apnea, arthritis, and other problems. Francis, who weighs more than 500 pounds, is well aware of
the risks:
When I was a young boy, people always said By the time you are 20 you are going to have a heart
attack and you could be dead. Well, I am 28 now. So, what Im afraid of is that Im on borrowed
time... I am morbidly obese, where it is almost certain I will die because of my weight problem.
Shannon Holten
Shannon's story comes from the news program Fault Lines.5 The United States incarcerates more
of its residents than any other nation on earth; fully 1% of American adults are being held in jail
and prison at any given time. In the 1970s the state-run asylums which used to hold many of the
mentally ill in America were closed down. Many of their patients were released onto the streets.
Inevitable interactions with law enforcement agencies have led many to be incarcerated. It is
estimated that the mentally ill make up as much as half the prison population. Shannon Holten, a
mother of three, has been incarcerated 26 times. Her most recent charges are for drug possession:
My psychiatrist told me that I self-medicate when I dont take my medicine... I have post-traumatic
stress disorder, OCD, schizophrenia, insomnia... I cant handle [incarceration]. Its real loud. Its
like chaos. Fighting, all of that. I have bad anxiety disorder where I pull my hair out when my
anxiety gets real high. Its just real, real hard to deal with.
Laxmi, Francis, and Shannon each face challenges to their health. For more than a decade, Laxmi's
HIV diagnosis left her isolated and cut off from her society, but access to medication and social
support have transformed her experience. She still carries the virus, but now has discovered new
meaning in her life counseling others with the disease. Laxmi shows us that a person can have a
disease, yet still find ways to live a healthy life.
Francis is aware that his morbid obesity places him at great risk for death. What factors may have
contributed to his weight problems? Individual decisions have certainly played a role (e.g., what
foods to eat, how much to exercise), but what role has his environment played? Did the grocery
stores in his community offer a selection of fresh fruits and vegetables, or was fast food the only
option? Did safe sidewalks and a low crime rate allow Francis to play outdoors as a child, or did
unsafe conditions make it much easier to stay indoors? Francis's condition highlights the fact that
health can be influenced by the complex interactions of many factors.
Shannon spends each day incarcerated. What impact does this have on her health and on that of
her three children? How might problems accessing healthcare have contributed to Shannon's
current legal troubles? What could and should be done to Shannon, and those like her, whose
mental illness brings them into conflict with the law?
People and Problem Focus
Public health is, by its nature, applied: working at boundaries where science and technology
interact with human health. Whereas much of modern science may take place in a lab, public
health tends to be carried out in real-world settings. Public health relies heavily on natural
experiments to understand the factors impacting human health, exploring health disparities among
populations and within populations over time.
This problem focused approach has allowed public health to make significant contributions to
human well-being. Since 1900, the average lifespan of a resident of the United States has increased
by more than 30 years. A study seeking to understand this increase in longevity determined that
only 5 years of the increase were due to medical science; the remaining 25 could be attributed
to public health advances. An examination of the changes in leading causes of death over time
illustrates how these gains have been made:

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Leading Causes of Death, United States

1900
1. Pneumonia and influenza
2. Tuberculosis
3. Diarrhea
4. Heart disease
5. Stroke
6. Kidney disease
7. Accidents
8. Cancer
9. Senility/dementia
10. Diphtheria

2000
1. Heart disease
2. Cancer
3. Stroke
4. COPD
5. Accidents
6. Diabetes
7. Influenza and pneumonia
8. Alzheimer disease (dementia)
9. Kidney disease
10. Septicemia

In 1900, the top three causes of death were due to infectious diseases. By 2000 advances in
sanitation and infection control had caused significant drops in these diseases, and their
replacement at the top of list by diseases linked to behaviors like smoking, poor diet, and physical
inactivity. These changes in the leading causes of death have led to a corresponding shift in the
focus of public health efforts. Reducing tobacco use, increasing physical activity, and promoting
healthier eating are major efforts in the modern public health movement.
A Broad View of Problems
There are several ways in which Public Health takes a broad view of problems. First, public health
focuses on populations rather than individuals. Examining health at the population level has
allowed public health to identify solutions to big problems that are not readily apparent to
individuals. This is illustrated by the example of automotive safety. Safety belts, child safety seats,
crumple zones, and airbags dramatically reduce the risk of serious injury or death in the event of an
accident. These safety features add to the cost of car manufacturing, and if left as optional features
may well be left off by the average consumer. The truth of the matter is that these features provide
little benefit to the average driver or passenger at the individual level, because most of us are not
involved in a serious accident. At the societal level, however, they have led to dramatic reductions
in per-mile fatality rates, and the fact that they are present in most vehicles is of great benefit to
those who are in are unfortunate enough to be in accidents.
A second way in which public health takes a broad view is in its rejection of reductionism. Public
health examines problems in the complex systems in which they arise. While many branches of
science seek to focus on ever smaller levels of organization, whether it is genetics in biology or
quantum mechanics in physics, public health seeks to examine issues in their naturally occurring
context. Increasingly, public health is seeking to understand the complex, multi-level factors that
shape human behaviors and health, recognizing that public policies, neighborhood characteristics,
individual decisions, and genetic factors may all play important roles in health outcomes.
Finally, public health is interdisciplinary and draws on the resources of multiple fields to address
health problems. The Council on Education for Public Health (CEPH) recognizes five core
disciplines of public health:

Epidemiology Epidemiologists are those scientists who examine the distribution of

health and disease in person, place, and time. Epidemiology combines the biological
sciences with research methodology and statistics. In addition to making health findings, it
is often the job of epidemiologists to act as translators and communicators, helping the
public to understand health research and its implications. Undergraduate majors that
would prepare a person to study epidemiology include biology, pre-professional health
(medicine or nursing), mathematics, and communication.

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Environmental Health This portion of public health draws strongly on the natural
sciences. Environmental health scientists monitor the levels of contaminants in the
environment and seek to understand the impact of environmental factors on health. The
classic example of a practitioner of environmental health is a sanitarian working for the
local or state health department. Undergraduate majors in chemistry, biochemistry,
biology, and physics would help prepare a person to study environmental health science.

Health Education/Behavioral Science Workers in the field of health promotion seek

to apply the knowledge of epidemiologists to improve the health of populations. Knowing
what impacts health is of little use if those factors cannot be changed. It is those working in
health promotion that design effective interventions to help people improve their health by
eating healthier foods, quitting smoking, or getting more exercise. As an undergraduate, a
person could study nursing, dietetics, psychology, sociology, or the related social sciences in
preparation for a career in health behavior and health promotion.

Health Services Administration The business of health care is the domain of health
service managers. Those who study this field are trained to make decisions about how to
allocate limited resources to maximize the health of a population. Undergraduate majors
that would prepare a person to study health services management and policy include
business, economics, accounting, and political science.

Biostatistics Statistical methodologies are among the most important tools used by
researchers in any field. The past several decades have marked the discovery of increasingly
more powerful, and complex, statistical tools. These days many research scientists turn to
experts in the field of statistics to help them design and evaluate their studies.
Biostatisticians are trained in the structure and analysis of the study designs employed in
modern research, and help the research team to identify what conclusions they can draw
from a study and with how much certainty. A person wishing to become a biostatistician
should consider an undergraduate major such as mathematics or statistics.

Prevention of Problems
A public health worldview recognizes that it is often easier to avoid a problem rather than trying to
solve it. Prevention is the task of anticipating problems and addressing them in their earliest stages
when small changes may yield large results. There are several levels of prevention:

Primary Prevention - "Specific practices for the prevention of disease or mental

disorders in susceptible individuals or populations."

Secondary Prevention - "The prevention of recurrences or exacerbations of a disease

that already has been diagnosed."

Tertiary Prevention - "Measures aimed at providing appropriate supportive and

rehabilitative services to minimize morbidity and maximize quality of life after a long-term
disease or injury is present."

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